Basic Information
| Provider Information | |||||||||
| NPI: | 1871687962 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HPCN | ||||||||
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| OtherOrganizationName: | LAKESHORE MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 905 E COLBY ST | ||||||||
| Address2: | PO BOX 189 | ||||||||
| City: | WHITEHALL | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494611262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317285910 | ||||||||
| FaxNumber: | 2317285918 | ||||||||
| Practice Location | |||||||||
| Address1: | 905 E COLBY ST | ||||||||
| Address2: | |||||||||
| City: | WHITEHALL | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494611262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317285910 | ||||||||
| FaxNumber: | 2317285918 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 01/15/2014 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | COLLEEN | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE EXECUTIVE | ||||||||
| AuthorizedOfficialTelephone: | 2317285910 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | C.M.P.E | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | MI | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.